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August 29, 2024

CERT Error: Insufficient Documentation for Cardiac Procedures

CGS developed this fact sheet to address the high Comprehensive Error Rate Testing (CERT) error rate related to insufficient documentation for cardiac procedures. If the CERT contractor selects your claim for review, please reference the information below to ensure you submit all related documentation for the procedure or service performed and the dates of service requested.

Required Documentation

  • All documentation to support all billed codes
  • Anesthesia and/or sedation record
  • Diagnostic test results/reports, including imaging reports
  • Discharge summary/discharge notes
  • Emergency room records
  • Evaluation & management/counseling notes
  • History and physical (PCP, other physicians related to treatment to support medical necessity of procedure)
  • Hospital history and physical
  • Implant log
  • Intra-operative record
  • Medication Administration Records
  • Nurse's notes
  • Observation orders and progress notes for each day
  • Operative reports and procedure notes
  • Peri-operative record
  • Physician orders or intent to order for the billed dates of service
  • Physician/non-physician practitioner (NPP) progress notes
  • Plan of care (may be part of evaluation)
  • Psychosocial evaluation, if applicable
  • Recovery room record
  • Reevaluations, when performed
  • Advance Beneficiary Notice of Noncoverage (ABN) issued to the beneficiary for each date of service and each specific service, when applicable
  • For electronic health records, send a copy of the electronic signature policy and procedures that describe how notes and orders are signed and dated.

Documentation from Outside Offices

If relevant to the procedure, obtain the following records from outside offices prior to submitting medical records to the CERT contractor for review:

  • Clinic/office notes
  • Consultation reports (outpatient or inpatient)

Documentation Related to National Coverage Determinations (NCDs)

  • NCD 20.32 – Transcatheter Aortic Valve Replacement (TAVR)External Website
    1. The patient (preoperatively and postoperatively) is under the care of a heart team: a cohesive, multi-disciplinary team of medical professionals. The heart team concept embodies collaboration and dedication across medical specialties to offer optimal patient-centered care. The heart team includes the following:
      1. Cardiac surgeon and an interventional cardiologist experienced in the care and treatment of aortic stenosis who have:
        1. Independently examined the patient face-to-face, evaluated the patient’s suitability for surgical aortic valve replacement (SAVR), TAVR or medical or palliative therapy.
        2. Documented and made available to the other heart team members the rationale for their clinical judgment.
      2. Providers from other physician groups as well as advanced patient practitioners, nurses, research personnel and administrators.
    2. The heart team's interventional cardiologist(s) and cardiac surgeon(s) must jointly participate in the intra-operative technical aspects of TAVR.
  • Shared Decision Making (SDM) Requirements

    Medicare providers must document SDM encounters in the medical record prior to implanting Left Atrial Appendage Closures (LAACs) and/or Implantable Cardioverter Defibrillators (ICDs).

    SDM integrates the use of evidence-based decision tools, which often include treatment pictograms, to characterize benefits and harms. This helps patients better understand treatment options and choose the most desirable treatment course.

    Documentation must indicate:

    • SDM occurred prior to LAAC or ICD implantation.
    • Benefits and harms discussed with the patient.
    • Any necessary calculations related to risk scoring.
    • The name of the evidence-based SDM tool(s) used to aid the patient in better understanding treatment options and choosing the treatment course.
    • The best rationale to seek a non-pharmacologic alternative to warfarin, considering the safety and effectiveness of the device compared to anticoagulation.
    • The result of the evidence-based SDM tool, after the provider informs the patient of the risks of LAAC or ICD implantation and any reasonable alternative management strategies.

    The name of the tool used and score total must be contained within the medical record.

  • NCD 20.34 – Percutaneous Left Atrial Appendage Closure (LAAC)External Website

    A formal shared decision-making interaction with an independent, non-interventional physician (other than implanter, like a primary care physician (PCP), non-interventional cardiologist, or neurologist) using an evidence-based decision tool on oral anticoagulation in patients with NVAF prior to LAAC interaction must be documented in the medical record.

  • NCD 20.4 – Implantable Cardioverter Defibrillators (ICDs)External Website

    A formal shared decision-making interaction with a physician or qualified non-physician practitioner (e.g., physician assistant, nurse practitioner, or clinical nurse specialist) using an evidence-based decision tool on ICDs prior to initial ICD implantation must be documented. The shared decision-making encounter may occur at a separate visit.

BEFORE YOU SEND DOCUMENTATION

Check for signatures on office/progress notes or other medical record documentation. If the signature(s) are missing or illegible, send a completed signature attestation. If the signature(s) are illegible, you may also send a signature log.

Additional Resources

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